Fixing Medicare, For Real

I’m a big fan of Matt Miller’s columns and books about domestic public policy. Today, he has a very good column about the real problem with Medicare. Here’s the most important point:

Rightly understood, health-care entitlement reform is not, as conservatives suggest, a matter of lessening the dependency of big chunks of the population on government largesse. It’s about weaning the members of our medical-industrial complex from their entitlement to far higher payments, despite shabby results, than their counterparts abroad get. This license for inefficiency, issued by both parties to doctors, hospitals, health plans, drugmakers and device firms, is diverting precious resources in an aging America from urgent non-health care, non-elderly needs.

Matt promises future columns about how to get that done–and I won’t be surprised if this involves replacing fee-for-service medicine with salaries for doctors and a heavy reliance on electronic record-keeping and best practices that I described in my piece about the death of my parents. Atul Gawande, who has done some of the very best writing about our medical system, makes a similar point in his recent New Yorker piece comparing the way the Cheesecake Factory works to the current chaos of our medical system.

The real frustration for me here, as with so many other issues we face today, is that there are good answers out there–but they are unattainable because of political gridlock and the entrenched powers that special interests have in a mature democracy. In his Time magazine interview this week, Mitt Romney talked about the inability of government to react to change as well as private enterprise does. True enough. There’s no creative destruction in government–but there’s also tremendous amounts of money staked on the status quo. We need to address both, but I’m not very optimistic that we will.

The problem is that no matter how you frame the issue, it means "less care." It may mean less unnecessary care, but who's to say what's unnecessary? Who are the senior citizens who are going to volunteer for "less care?" Given a choice between less medical care and more medical care, people almost always want the latter.

Part of it is how Americans are. I read an account by a British doctor who had cancer, so for a time, he was both an employee and a patient in the British NHS. He knew the protocol as well as his doctor did, and when the last drug on the flowchart didn't work, the two just stared at each other. From now on, there would be no more treatment, only palliative care. The thing was, the doctor still didn't even feel that ill. This was when he wrote the article, and he eventually died of course. I wish I still had the link but I lost it.

Can anyone imagine Americans accepting that? Getting to a point where it's, well, we'll just have to let Nature take its course? No way. To the very end, it's always, "But there must be something you can try, doctor!"

Fee-for-service results in 89-year-olds like my dad being driven to the doctor's "office" -- more like the waiting room, actually -- sitting for an hour, having a "nurse" take their blood pressure, and then sitting in another, private little room with a paper-covered examining couch. Then the doctor comes in, re-takes the blood pressure, asks a question or two, and tells [me] to schedule another appointment in six months. Most questions from [me] result in a quick look of interruption, then brief consideration, and then a suggestion for some test or medication.

Do you understand the proposal? The amount of the voucher will be keyed to the cost of a variety of insurance plans (specifically, the second cheapest) that must meet a minimum coverage level. If you want more you can choose a different plan and pay more, which keeps the rest of us from paying for something we don't need/want but may be important to someone else. And that would be my decision. It bothers me that many think we're too stupid to determine our own needs and need to rely on someone else to decide for us.

Why not just fix the business cycle by installing a command control economy as the present administration is promoting? However, there are a few problems with that, some but not limited to the lack of high quality medical staff, pharmaceuticals, prosthesis, equipment and hospitals. Other than that, it's a great idea.

I once worked for a giant filing conglomerate that specialized in medical records. They had four warehouses filled with banker's boxes (think the ending of Raiders of the Lost Ark). Hojillions of files. Literally. Hojillions.

Once, one of the untrained minimum wage goobers drove a forklift (OSHA who?) into one of the myriad shelves of files, causing a hilarious domino effect made only more laughable by the fact that I was immediately promoted to forklift operator.

The less hilarious part was when they just wrote that aisle off as totaled, leaving thousands and thousands of medical records to form low income housing for rats and cockroaches. A year later, it was a mountain of filth and pestilence. Also, bad feng shui. Also, the plague.

Someone telling me that cutting the mammoth excess involved in paying a whole company's worth of expenses on shuffling all this superfluous paper could be achieved by going electronic would probably garner less of a raised eyebrow from me than usual.

Besides, think of the fortune to be made by all those entry level data entry people! They'll be compensated fairly, right? u_u

Neither Romney nor Obama have any real plans based on what they have said on the campaign trail. Neither of the two are willing to move doctors to a salaried system. And the system does need to be setup such that the government only pays up to a point if you are over 65 years old. It is not free service. Where the marketplace should come in is to potentially offer supplementary insurance beyond the government supported baseline that people who have saved up for retirement can pay for out of their own pocket.

I'm curious to see how universal coverage will affect prices. I'm curious to see the long-term effect of Obamacare's medical loss ratio requirements. I'm curious to see how much savings can be brought about from updating practices, computerized medical records, that kind of thing. (Though we won't get a true picture of any of this, because of Republican intransigence.)

Be vigilant and wake up America before it is too late! Praise be to Gawker.com, Wikileaks and the power of the internet. Doubtlessly with the revelations, it is confirmed that Romney is a cheat, liar, fraud and a criminal unfit to be President. He can never be trusted at his word. Since the wheels of justice turn ever so slowly, Romney has yet remained untouchable due to money, power, influence and the perverse double standard of justice for the rich and for the poor. It is interesting to note the overzealousness of Romney, Ryan and the entire Republican Tea Potties in buying the presidency at all costs with the backing of 33 billionaire donors to his campaign of mass deception, in their hunger for absolute power, total control and unbridled monopoly in the USA and in a new world order. Is it any wonder then that in the history of the USA, President Barack Obama is the first black United States President after 235 years of white monopoly of the White House?

"The real frustration for me here, as with so many other issues we face today, is that there are good answers out there–but they are unattainable because of political gridlock and the entrenched powers that special interests have in a mature democracy."

and

"there’s also tremendous amounts of money staked on the status quo."

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This is exactly correct and affects so many areas of policy, not just health care. This is why it is so hard to make any changes to energy policy, industrial policy, fiscal policy... etc... etc...

How about this....In exchange for participating in a salaried practice, which admisters primarily to publicly-funded insurance, the practicioner is shielded from malpractice claims in all-but gross negligence cases. Plus, in exchange for this work, the government underrites med school loans and forgives the debt at a rate of 10% per year of this service (with an annual cap - the govt cannot afford Harvard Med). That way, someone who really WANTS TO PRACTICE MEDICINE doesn't have to worry about marketing or lawyers (and gets a fair wage).

This is a problem that can be solved...Congress just lacks the creativity to do so.

"...the inability of government to react to change as well as private enterprise does. True enough. There’s no creative destruction in government–but there’s also tremendous amounts of money staked on the status quo."

Good lord. Our "counterparts abroad" are able to control costs because "private enterprise" doesn't (completely) control their governments. When are you going to get over your simple-minded, anti-liberal infatuation with so-called "market forces"? In this case, as in many others, they're the problem and the reason behind "the inability of government to react to change."

Its health care that needs to be addressed. Do away with Medicare/Medicaid and what you will have is a bunch of uninsured people and people with private insurance paying through the roof for health care.

My wife and I are gouged an insane amount monthly by our health insurance company due to her pre existing conditions, so here is my two cents -

The political gridlock that Joe speaks about is primarily due to the efforts of one party. No need to mention them by name, but they have a big meeting in Florida next week. Until they come to grips with the notion of healthcare being a “right”, and stop using the term “socialized medicine”, I don’t see anything positive being done. Healthcare needs to no longer be looked at as a profit driven commodity. Once we admit the unique importance of healthcare, we can dispense with the notion that it is just another form of free enterprise. This requires a major paradigm shift that isn’t evident in the present environment. It’s all a case of things having to get much worse, before they get better.

Entrenched interests can be dealt with if we had public financing of elections, where those that have the decision in fixing this medical/industrial system on a national basis (not by state) aren’t beholden to these entities for campaign donations. Pilot plans can be developed by states, but ultimately, if the consensus is that healthcare is a right, then a national solution is required. That’s the only way you can ever have equal access for all strata of society. Sort of Medicare for all

As for the medical community, if you want to attend med school, get your head screwed on right and think about why you are going it. Is it primarily to make as much dough as possible, or is it to serve the public? A combination of both doesn’t seem to be working. Perhaps some thought should be given to the public assisting in tuition expenses for med students, and in return they provide at least two years of public service. When they do go into private practice they then wouldn’t have that massive tuition to face. It would be a way for society to make an investment in their own healthcare.

I agree with you about Matt Miller. He is also, by the way, a nice guy. I don't always agree with him, but he'll offer a little debate in response to polite correspondence. I don't want to wade into "death panels," here but one of my problems with the whole "electronic record keeping to monitor best practices," arguments is that I am not an average person, nor am I the mean. My own medical circumstances, though related to the data out there (of course) and to the experience of others, are also unique. It's like when you go to the gym and see that one guy gets lean and ripped by lifting heavy weights while another guy has to do crazy amounts of cardio. How do we standardize care when the human experience is just not all that standardized?

Gawande is the most authoritative and innovative figure in healthcare writing at the moment, but I'm not sold that going with big chains is the correct direction to take hospitals. With systems sprouting left and right, the negotiating power of hospitals increases tremendously. While in theory that means they can get discounts on drugs and devices, those savings aren't going to reduce costs; it's going straight to the head honchos. Economies of scale (like consolidated billing offices) are much more efficient and save a lot, but again, there is no guarantee those savings will translate to the consumer. Conversely, as the systems grow in size, it increases their clout against government programs like Medicare and Medicaid.

Ultimately I agree with Mr. Klein that fee-for-service has to go, and luckily the ACA starts to chip away at the inefficient system.